Ruminations by a non-academic general surgeon from the heart of the rust belt.

Friday, August 8, 2008

Superbugs

Great article from Dr Jerome Groopman in this week's New Yorker about the rise of the so-called "superbugs" in hospitals, especially ICU's, across the country. We all have heard of MRSA (methicillin resistant staph aureus), but it is the lesser known gram negative entities that are actually more frightening. At least with MRSA, you have options; vancomycin, doxycycline, and daptinomycin, etc. With these gram negative organisms, there is no anti-microbial of last resort. Basically, we're dealing with an infectious organism that cannot be treated with current pharmaceutics.

Enterobacter and Pseudomonas and Acinetobacter and Klebsiella are the names. These aren't new organisms; just hardier versions of bugs that have been around for thousands of millenia. Normally they exist harmlessly in our intestinal tract but with the rise of antibiotic resistance, these heretofore harmless bugs have acquired a newfound virulence. Patients are dying from pneumonias and urinary tract infections just like patients did a hundred years ago in the preantibiotic era. Thirty years of needless antibiotic prescriptions for virally mediated upper respiratory tract infections has brought us to the brink of this new plague. (In the article, a 1998 study is cited estimating that 55% of all antibiotic prescriptions for respiratory infections {i.e the common cold} in outpatients- 22.6 million- were unnecessary.)

I've been involved in the care of a few patients with acinetobacter baumanii infections. It's awful, a harbinger of doom. The poor patient gets shunted off into some peripheral isolation room and you basically have to don a HazMat outfit if you want to enter the room. Bunny suit, shoe covers, mask, gloves, bouffant cap for your head, and then, finally, an overgown, just to make sure you're as hot and uncomfortable as possible. Which inevitably leads to physicians conducting the LGFTD form of rounds (looks good from the door), invariably leading to neglect and further isolation.

You would think that Big Pharma would be the driving force behind a search for newer, more effective therapies for these bugs. Shockingly, that couldn't be further from the truth.

After Squibb merged with Bristol-Myers, they closed their antibacterial program,” he said, as did Abbott, which developed key agents in the past treatment of gram-negative bacteria. A recent assessment of progress in the field, from U.C.L.A., concluded, “FDA approval of new antibacterial agents decreased by 56 per cent over the past 20 years (1998-2002 vs. 1983-1987),” noting that, in the researchers’ projection of future development only six of the five hundred and six drugs currently being developed were new antibacterial agents

Apparently, the antimicrobial business just doesn't cut it in terms of profit margins. Why make a potentially life saving, plague averting antimicrobial that just gets used for a week or two for a highly select group of patients when you can spend all your R&D on making things like Lipitor (still no data to suggest there is a long term link between cholesterol levels and heart disease) and Prilosec (keeping the world safe from the ravages of GERD!!!), pills that get used every day for the extent of a person's life. Easy choice, right?

8 comments:

Fiamma
said...

Such a great post. It amazes me how people overdose for colds and allergies. let your body fight stuff off once in awhile please.What does not surprise me is that Big Pharam cares more about my cholesterol than how many of these bacteria keep becoming resilient due to misuse of antibiotics. I am sure they could cure cancer, but a hard on and restless leg syndrome trump that it seems.

Unfortunately, it's a lot faster for doctors to just whip out a prescription pad and cave in to that request for unnecessary antibiotics than to take the time to explain why antibiotics are not needed and why overuse of antibiotics is harmful in the future. As a doctor in training, I still have the energy to fight the fight, but I can feel myself giving way more and more, especially when my colleagues who give antibiotics when they're unnecessary are considered better doctors by their patients than someone who's stingy with the script pad like me.

Your disappointment in the lack of R&D in the antibacterial sector is admirable, but lets be realistic. No drug company is going to develop new drugs out of some philanthropic desire to help the nation. And with and FDA approval reduction of 56%, it seems they should be the ones taking the brunt of the blame here. By no means am I a proponent of drug companies, just a realist.

Dear realists out there - please allow me to be even more realistic here: Let's say that one day your child comes down with a bad stomachache that's happened to be caused by VRE (vancomycin-resistant enterococcus). Thanks to your market force driven realism, doctors no longer have antibiotics in their arsenal able to keep the infection at bay and helps your little one. What good would your profit and market strategies do to your child then?

As an additional disincentive to develop new antibiotics, I recall that during the anthrax scare in 2001, people were talking about governmental action to get around the Bayer patent on Cipro, then considered the drug of choice, to keep the manufacturer from excessively profiting from its life-saving invention. Sometimes a wonder drug can be just too wonderful.

My name is Janice Still and i would like to show you my personal experience with Lipitor.

I have taken for 2 years. I am 56 years old. Lipitor worked great lowering cholesterol but the side effects are not worth the benefit.

I have experienced some of these side effects-Achilles peritendonitis and sore ankles, knees and fingers. Stiffness was aggravated by rest and better with activity. After sitting for 15 minutes, particularly with feet elevated, and then getting up to walk, my gait was like someone who could barely walk. Have stopped taking Lipitor and symptoms seem to be subsiding.

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